WHITIER CITY SCHOOL DISTRICT

Athleticand Activity/Club Registration Form 2017/2018

All prospective participants must complete these materials, provide proof of medical insurance and have a parent/guardian signature authorizing their participation prior to participation in any activity or practice.

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Student Name (Please Print)SchoolDate of Birth Grade

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Address - StreetApt.CityZipHome Phone

CALIFORNIA LAW

The California Education Code (Sections 32221-32224 and 49470-49474) requires that each member of an athletic team shall have insurance coverage for medical and hospital expenses in an amount of at least $1,500 while practicing for or participating in athletic activities under the jurisdiction of a public school district. "Member of an athletic team" means member of any extramural athletic team engaged in athletic events on or outside the school grounds, maintained or sponsored by the educational institution or a student body organization thereof. "Member of an athletic team" also includes members of school bands or orchestras, cheerleaders and their assistants, pompon girls, team managers and their assistants, and any student or pupil selected by the school or student body organization to directly assist in the conduct of the athletic event, including activities incidental thereto, but only while such members are being transported by or under the sponsorship or arrangements of the educational institution or a student body organization thereof to or from a school or other place of instruction and the place at which the athletic event is being conducted.

Under state law, school districts are required to ensure that all members of school athletic teams have accidental injury insurance that covers medical and hospital expenses. This insurance requirement can be met by the school district offering insurance or other health benefits that cover medical and hospital expenses. Some pupils may qualify to enroll in no-cost or low-cost local, state or federally insured program. Contact LACOE Health Outreach Program at 562-922-8954 for low-cost health programs.

INSURANCE PROTECTION

Parents/Guardians must provide proof of insurance and complete and sign the following athletic waiver of insurance as evidence of other insurance coverage,or purchase Student Accident Insurance made available by the Whittier City School District before the student is eligible to participate in athletic events.

Option A Personal Insurance - I hereby declare that my student, ______,

has medical insurance in the amount of at least $1,500 administered by ______

Insurance Co., Policy #______, which will provide coverage for medical and hospital expenses resulting from accidental bodily injury while practicing for or participating in athletic events. Therefore, I do not want my student to subscribe to membership in the insurance program made available through the school district for accidental bodily injury and hereby release the Governing Board and school officials of the Whittier City School District from any and all responsibility to provide the insurance required under California Education Code Section 32220-32224. I WILL NOTIFY THE SCHOOL OF ANY CHANGE OR LAPSE IN THE ABOVE COVERAGE.

A copy of student’s proof of medical insurance is attached.

______Date______

Signature of Parent/Guardian

Option B I wish to participate in the Student Accident Plan made available by Whittier City School District.

An insurance enrollment form should accompany this form, or you can obtain one online at the Student Insuranceprovider website.

  1. Log on to “Products”, click on “Student Accident & Health Insurance”, then click the appropriate link for a Brochure in English or Spanish. You may also sign up online and print proof of your coverage (attach to this document) OR
  2. Print Brochure, complete and bring to your coach or teacher to forward to the insurance company with your payment.

A copy of student’s proof of insurance is attached.

______Date______

Signature of Parent/Guardian

SPORTS WARNING STATEMENT

Participating in competitive athletics may result in severe injury, including paralysis or death. Players can reduce the risk by reporting all physical problems to their coaches, following coaches’ instructions regarding playing techniques, training and other team rules, etc., and agreeing to obey such instructions. Even if all these requirements are met, a serious accident may still occur.

PARENT PERMISSION

In consideration of the permission granted, we, the undersigned, hereby RELEASE, DISCHARGE and HOLD HARMLESS the Whittier City School District from all liability arising out of or in connection with the identified athletic sport/activity. The release and discharge of the Whittier City School District from all liability includes any defect or alleged negligence attributed to the Whittier City School District or any of its coaches, agents, instructors, teachers or any assistants supervising, directing or instructing in the athletic sport/activity. (______)(to be initialed by the student and/or parent or guardian)

I, ______, being the parent/legal guardian of ______(student), have read the above release. I understand and agree to its terms. I understand that all sports can involve MANY RISKS OF INJURY including, but not limited to, those risks outlined above.

In the event of an accident, or sudden illness, the school district has my permission to render whatever emergency medical treatment may be deemed necessary for the above named student.

I am signing this document on my own behalf, as well as on behalf of my student athlete.

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Signature of Parent/GuardianDate